Provider Demographics
NPI:1467837344
Name:CHARRON, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:CHARRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 SW UMATILLA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-7039
Mailing Address - Country:US
Mailing Address - Phone:541-504-3900
Mailing Address - Fax:541-504-3907
Practice Address - Street 1:411 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:OR
Practice Address - Zip Code:97378-1117
Practice Address - Country:US
Practice Address - Phone:888-468-0022
Practice Address - Fax:541-504-3907
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD102991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice